AUTHORIZATION TO REQUEST / RELEASE INFORMATION
Consent
I give consent:
Agency Information
Information to be Requested or Released
Purpose
The purpose of this disclosure is to improve assessment and treatment planning, share relevant information, and coordinate treatment services.
If other purpose, please specify:
Revocation
I understand that I may revoke this authorization in writing at any time by contacting NAK Union Behavioral Health at 5530 Old National HWY, Bldg. C, Ste. B, College Park, GA 30349. Revocation will not affect prior releases made in reliance on this authorization.
Expiration
Unless revoked sooner, this authorization expires ONE YEAR FROM THE DATE OF SIGNATURE.
Conditions
NAK Union Behavioral Health will not condition treatment on this authorization. However, refusal to sign may hinder services or prevent proper advocacy, and NAK Union Behavioral Health may discontinue services if refusal poses a danger or limits care.
Form of Disclosure
Information may be disclosed verbally, on paper, or electronically unless a specific format is requested in writing.
Re-disclosure
Federal law prohibits re-disclosure of substance abuse information without written consent. Other information may be re-disclosed in emergencies.
Signature Section
Additional Information
